1. What’s the Big Deal about Vitamin D?
Rebecca B. Saenz, MD, IBCLC, FABM
Mississippi Breastfeeding Medicine Clinic, PLLC
Madison, Mississippi

2. In the news
And on the Web

3. What is Vitamin D? Actually, a hormone
Receptors in many organ systems –
Bone, skeletal muscle, brain, prostate, breast, colon, pancreas, immune cells
Vitamin D2 = calciferol – about 30% activity of D3
Vitamin D3 = cholecalciferol

4. Vitamin D synthesis Vit D from skin or diet >
Metab in liver to 25-OH-Vit D >
Metab in kidneys to 1,25-diOH-Vitamin D3
Regulated by parathyroid hormone and serum calcium and phosphorus
Excess 25-OH-Vit D and 1,25-diOH-Vit D are catabolized into inactive calcitroic acid and excreted in bile

5. What Vitamin D does-- Increases calcium and phosphorus absorption
Enhances bone mineral density
Increases insulin production in pancreas
Decreases renin production in kidneys
Immunomodulatory
Anti-inflammatory
Role in preventing genetic expression of some cancers (local effect)

6. Disease States
Skeletal – rickets, osteopenia, osteoporosis, osteomalacia, fracture
Muscular– weakness, twitches
Skin -- psoriasis
Cardiac – hypertension, CHF, inc. CRP
Pulmonary – wheezing illnesses
Immune – diabetes, MS, Crohn’s, RA, OA
Psychiatric – schizophrenia, depression
Other – prostate, colon, & breast cancers, and non-Hodgkins lymphoma

7. (measured as serum 25-OH-Vit D levels)
Vitamin D levels
(measured as serum 25-OH-Vit D levels)
Deficiency < 20ng/ml
Insufficiency = 21-29ng/ml
Sufficiency >30ng/ml
Preferred range = 30-60ng/ml
Intoxication >150ng/ml

8. Sources of Vitamin D Sunshine – ultraviolet B radiation (290-315nm)
0.5 “minimal erythemal dose”* gives
about 3000IU of vitamin D3
*0.5 minimal erythemal dose =
about 5-10** minutes of exposure
of arms and legs to direct sunshine,
**Depending on time of day, season, cloud
cover, extent of air pollution, latitude, body
mass, amount of exposed skin, UVB protection,
and skin sensitivity (complexion & genetics)

9. It’s GOOD in moderation!
A word about sunshine . . .
It’s GOOD in moderation!
10-15 minutes daily
Short sleeves and pants
Without hat or sunscreen
SPF 15 or higher blocks 99% of UVB
What about risk of skin cancer?
Apply sunscreen after those first minutes!

10. “It is virtually impossible to get enough sunshine from November to February above 35 degrees latitude* to stay “sufficient”.
*35 degrees latitude is the north border of Georgia, Alabama, and Mississippi, and cuts Arkansas in half just north of Little Rock

11. Sources of Vitamin D Dietary (Adults) Salmon 100-1000 IU
Sardines IU
Mackerel IU
Tuna IU
Cod liver oil IU
Shitake mushrooms IU
Egg yolk IU

12. Sources of Vitamin D Dietary (“Fortified”)
Milk, OJ, yogurt, IU/8oz
Infant formula IU/8oz
Butter IU/3.5oz
Margarine IU/3.5oz
Cheeses IU/3oz
Breakfast cereals IU/serving

13. Sources of Vitamin D Dietary Supplements Prescription Over the Counter
Vitamin D2 (ergocalciferol) 50,000IU/cap
Drisdol liquid vit D2 8,000IU/ml
Over the Counter
Multivitamin / Prenatal 400IU
Vitamin D , 800, 1000, or 2000 IU
Infant drops IU/dose

14. Sources of Vitamin D Dietary (Infants)
Human Breast Milk Vitamin D content varies based on Mom’s Vitamin D status,
which varies based on her
sunlight exposure and dietary intake.
Range: IU / liter, if mom unsupplemented
Up to >800 IU / liter if mom on high-dose Vit D

15. DATE: August 29, 2008
It is clear that vitamin D content of human milk is variable and directly related to maternal vitamin D status. Human milk is not deficient in vitamin D per se; rather, it is deficient in vitamin D when mother is deficient. Vitamin D transfer into mothers’ milk is predictable: a deficient woman has little to transfer to her infant via her milk; if her status improves, transfer of vitamin D in her milk to the baby will also. Maternal vitamin D deficiency and resultant nutritional rickets in her nursing infant is preventable: supplementation of the infant with vitamin D will ameliorate deficiency in that age group, but does not address maternal needs. Adverse effects associated with vitamin D deficiency affect bone development and innate immunity such that no woman and her baby should be deficient. We must prescribe a safe intervention that will achieve sufficiency in both mother and infant and not blame human milk as the culprit, but rather, see the problem as the larger public health issue that it is.
Caroline Chantry, MD Karla Shepard Rubinger
President Executive Director
Academy of Breastfeeding Medicine Academy of Breastfeeding Medicine
140 Huguenot Street, 3rd floor
New Rochelle, NY

16. Human Breast Milk is not deficient in Vitamin D; Modern life is deficient in sunshine!

17. Risk Factors for Vit D Deficiency
Reduced skin synth
Sunscreen
Pigment
Aging
Season/latitude/time
Skin grafts
Dec. bioavailability
Malabsorption
Cystic fibrosis
Celiac disease
Crohn’s disease
Gastric Bypass surgery
Cholesterol lowering meds
Obesity

18. Risk Factors for Vit D Deficiency
Increased catabolism
Anticonvulsants
Glucocorticoids
Others
Increased urinary loss of 25-OH-D
Nephrotic syndrome
Decreased synthesis of 25-OH-D
Liver failure
Decreased synthesis of 1,25-diOH-D
Chronic kidney disease

19. Risk Factors for Vit D Deficiency
Heritable Disorders – (Rickets)
Vit D dependent rickets – type 1
Vit D resistant rickets
Vit D dependent rickets – type 3
AD hypophosatemic rickets
X-linked hypophosphatemic rickets
Acquired disorders
Tumor-induced osteomalacia
Primary hyperparathyroidism
Granulomatous disorders (sarcoid, TB)
Hyperthyroidism

20. Risk Factors for Vit D deficiency in infants
Mom who is “insufficient” or “deficient” during pregnancy or lactation
Baby is both exclusively breastfed
AND sheltered / protected from sunlight.
Babies born in fall/winter
Babies in full-time daycare
Living above 35 degrees N latitude
Babies born prematurely

21. Recommendations – Breastfeeding Babies
Vitamin D2 suppl is approx 30% as effective as vit D3 suppl – calculate accordingly!
AAP: 400 IU vitamin D3 / day
Sensible sun exposure
IU vitamin D3 / day is safe, if necessary to treat deficiency

22. Supplementation of the nursing infant with oral vitamin D
Supplementation of the nursing infant with oral vitamin D does not address the issue of why the antirachitic activity of the mother’s milk is low --- namely, that her vitamin D status is poor.
Wagner CL, Taylor SN, and Hollis BW. Does Vitamin D Make the World Go ‘Round? Breastfeeding Medicine 2008; 3(4):

23. Correlation of Maternal and Infant 25-OH-Vit D levels
Maternal Infant Maternal Infant
Vit D Vit D serum serum
Suppl Suppl (OH)D (OH)D
2000IU/day
4000IU/day
6400IU/day
400IU/day IU/day
From: Hollis BW, Wagner CL. Vitamin D requirements during lactation: high-dose maternal supplementation as therapy to prevent hypovitaminosis D for both the mother and the nursing infant. Am J Clin Nutr 2004; 80:Suppl 6:1752S-1758S.
Wagner C, Hulsey TC, Fanning D, et al High-dose vitamin D3 supplementation in a cohort of breastfeeding mothers and their infants: a six-month follow-up pilot study. Breastfeeding Medicine 1(2):59-70.

24. “We understand more fully now that this deficiency is not caused by something that is inherently wrong or missing in mother’s milk but rather by inadequate maternal dietary vitamin D intake and the resultant low concentrations in the mother’s milk.”
Wagner CL, Taylor SN, and Hollis BW. Does Vitamin D Make the World Go ‘Round? Breastfeeding Medicine 2008; 3(4):

25. Supplementation of Breastfeeding Mothers
“Lactating women given 4000 IU of vitamin D3 per day not only had an increase in the level of 25-OH vitamin D to more than 30 ng/ml, but were able to transfer enough vitamin D3 into their milk to satisfy an infant’s requirement.”
Hollis BW, Wagner CL. Vitamin D requirements during lactation: high-dose maternal supplementation as therapy to prevent hypovitaminosis D for both the mother and the nursing infant.
Am J Clin Nutr 2004; 80:Suppl 6:1752S-1758S.

26. “Recommendations” – Lactating Mothers
Vitamin D2 suppl is approx 30% as effective as vit D3 suppl – calculate accordingly!
1000 – 4000 IU vitamin D3 / day
50,000 IU vitamin D2 q 2 weeks to treat deficiency
Up to 4000 IU vitamin D3/day is safe for 5 mos
Up to 6400 IU / day has been used for 3 months without problems.

27. Summary
Vitamin D deficiency is much more widespread than previously thought
Vitamin D deficiency is a factor in many diseases, not only rickets and osteoporosis.
Modern life is deficient in sunshine, and thus in vitamin D.
Some form of vitamin D supplementation may be appropriate for many breastfeeding mothers / babies.

28. Summary
“In the future, we expect that by treating the mother with a sufficient dose of vitamin D, both mother and her recipient infant will achieve normal vitamin D status.”
Wagner CL, Taylor SN, and Hollis BW. Does Vitamin D Make the World Go ‘Round? Breastfeeding Medicine 2008; 3(4):

29. Mississippi Breastfeeding Medicine Clinic, PLLC
Rebecca B. Saenz,
MD, IBCLC, FABM
111-A Depot Drive
Madison, MS
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